Cesarean Section Rate - Summary

Cesarean section rates are rising and account for more than 30% of
childbirths in the USA.

This rise can be attributed to:

Relative safety of surgery with improvement in anesthesia,
availability of blood transfusion and antibiotics.

Greater emphasis on quality of offspring rather than quantity.

Patient preference based on claimed benefits of planned
caesarean section including greater safety for the baby, less pelvic
floor trauma for the mother, avoidance of labour pain and
convenience.

The potential disadvantages, include increased risk of major morbidity or
mortality for the mother, and problems in subsequent pregnancies, including
uterine scar rupture and greater risk of stillbirth and neonatal morbidity.

The decision on optimum mode of delivery is the most commonly
encountered question in clinical practice across all medical disciplines.

The number of factors to be taken into account is greater than
in any other clinical situation across all medical disciplines.

There is undoubtedly a risk of litigation issue colouring
obstetric decision making. An obstetrician is more likely to be subjected to
litigation because a cesarean section was not performed or was perceived to have
been performed too late than for complications of surgery. In the current
climate, it is likely that cesarean sections are likely to continue rising.

Cesarean Section Rates are on the increase but many believe this trend
should be reversed. what is the answer?

At first sight it would seem remarkable that we should in effect be saying
that "nature", which has kept the human race going for thousands of years, is so
inept that surgical intervention is required for a third of confinements. Not
surprisingly, many are questioning the validity of these interventions.

Samantha Shepherd had been in labour for three days when she was told by a
doctor that her baby's life would be in danger if she didn't have a Caesarean
section.

But the discussion was suddenly interrupted by the assistant
anaesthetist, Nigel Baglin, who banged the door with his trolley and
shouted: ' hell, why can't women in this hospital give birth naturally?'

Dr. Baglin defended his comments at a hearing, saying he'd simply
been 'aghast' at the number of Caesareans being carried out at Newham
University Hospital, East London.

Hospitals are 'fed up with too posh to push brigade' - but the wrong
women may end up being targeted

Baglin was cleared of misconduct and his comments reflect a wider
concern about Caesarean rates, with the Government and midwives
determined to reduce numbers.

Why are we increasingly resorting to Cesarean Section?

Figure 1. The cesarean section rate in the UK has
climbed above 20% in the UK and continues to rise by about 0.7% each
year.

Figure 2. Source: U.S. National Center for Health
Statistics

In December 2007, the National Center for Health
Statistics released the preliminary U.S. national cesarean rate for
2006: 31.1%.

Cesarean section has become relatively safe over the last half
century because of:-

safer anaesthesia including regional blocks including epidurals
and spinal blocks which can avoid general anaesthetic.

availability of blood transfusion.

antibiotics.

The two most common indications for cesarean section are

delay in labour

fetal distress

Delay in Labour

During normal vaginal delivery, the baby is expelled through the mother's
pelvis. Human supremacy involves a compromise between the physical adaptations
for bipedalism (walking on two legs) and encephalization (our brains are
relatively large).0801
The head is the largest part of a baby. As the human head is relatively large
and women's pelvises are relatively small compared to all other species we
commonly encounter "cephalo-pelvic disproportion" and this manifests itself by
delay in labour.

Partograms allow provide a means to document progress in labour including the
opening of the cervix (neck of the womb) and the descent of the baby into the
maternal pelvis. When there is evidence that progess is slow then an oxytocin
drip, which encourages the uterus to contract more and breaking the waters may
be employed to expedite delivery. If progress remains slow then operative
delivery will be indicated.

Fetal Distress

Until only the last two or three generations, couples had bigger families.
This was influenced by primitive contraception and the survival rates of
offspring was poor. In developed countries, we now have excellent contraception
and the majority of babies will survive. Quality of offspring has become the
prerequisite. As cesarean section has become safe, mothers are more than happy
to be delivered operatively to reduce the chance of their baby being damaged.

Before the 1960's the condition of the baby during labour was assessed by
checking the baby's heart rate intermittently with a fetal stethoscope -
auscultation. Then technical advances led to our ability to monitor the fetal
heart rate continuously - cardiotocography (CTG). Patterns of CTG abnormality
became associated with possible fetal compromise and unless delivery is
imminent, cesarean section is indicated. To reduce the number of cesarean
sections, many obstetricians perform fetal blood sampling and if there is no
evidence of increased acidity, then operative delivery might be avoidable. CTGs
have undoubtedly contributed to a rise in cesarean section rates.0801

The major concern with fetal distress is that it may lead to fetal demise or
damage the baby and in particular the brain leading to cerebral palsy or reduced
cerebral ability. There is extensive evidence that the majority of children born
with these conditions do not develop them during labour. Correlations between
degrees of fetal distress or duration of fetal distress leading to
morbidity are lacking. The author
believes that It is possible that monitoring the fetal brain itself might shed
light on this area but accurate technology has proven elusive to find.7902

Currently, we have no choice but to expedite delivery when there is reason to
be believe that delay could cause problems.

Additional factors increasing cesarean rates.

Too Posh To Push (see below)

Previous cesarean section. In the USA it would seem that vaginal
births after previous cesarean has fallen to almost nil although in
the UK we try for vaginal delivery whenever possible. In every
country, a previous cesarean increases the chance of a subsequent
cesarean.

Women are delaying their families and older women are more prone
to obstetric complications and more likely to require cesarean
delivery9101,
9601

Data from Canada in
the Health Policy Research Bulletin (following graphs) demonstrates the
complex dynamics behind recent fertility trends, including transformations in
family structure.

There has been a reduction in number of children
from 7 in 1871 to 1.5

Figure 3.

Women are delaying commencing their families. In
one generation the peak age for first child has moved from 22 years to 28
(1976-1996).

Figure 4.

The peak age for starting a family in women with university education is 35
compared to 31 in those who have not attended university.

Figure 5.

Older mothers are more prone to pregnancy
complications including high blood pressure and gestational diabetes.

These may contribute to cesarean rates rising.

Figure 6.

Fertility is reduced and miscarriage rates increase
with age.

As women leave their childbearing to later than previous generations, they
are more likely to encounter fertility difficulties and increased risk of
miscarriage. Pregnancies in women who have had such difficulties are considered
to be particularly precious and consequently the threshold for operative
delivery is lowered.

Figure 7.

"Too Posh To Push"

Perhaps the most contentious indication for cesarean section is maternal
request without obstetric indication.

The claimed benefits of planned caesarean section include greater safety for
the baby, less pelvic floor trauma for the mother, avoidance of labour pain and
convenience.

The potential disadvantages, include increased risk of major morbidity or
mortality for the mother, and problems in subsequent pregnancies, including
uterine scar rupture and greater risk of stillbirth and neonatal morbidity.

Requests for elective caesarean section in an uncomplicated pregnancyare not uncommon. Performing a caesarean section when it is not
clinically indicated has traditionally been considered inappropriate,
but views have changed. Public opinion is increasingly veering towards women
having a right to choose.0802

There is no evidence from randomised controlled trials, upon which to base
any practice recommendations regarding planned caesarean section for non-medical
reasons at term.0602

What are the Risks of Cesarean section?

Mortality is higher with cesarean section than vaginal delivery (relative
risk 3.7). There are, however, confounding factors. Cesarean section, however,
is more commonly performed when there are high risk factors such as severe
hypertension or placenta praevia which may predispose to mortality.

Morbidity is also higher with cesarean section. Rehospitalizations in the first
30 days after giving birth is more likely in planned cesarean (19.2 in 1,000)
when compared with planned vaginal births (7.5 in 1,000).0702
The leading causes of rehospitalization after a planned cesarean were wound
complications (6.6 in 1,000) (P<.001) and infection (3.3 in 1,000).

The average initial hospital cost of a planned primary cesarean of US dollars
4,372 (95% C.I. US dollars 4,293-4,451) was 76% higher than the average for
planned vaginal births of US dollars 2,487 (95% C.I. US dollars 2,481-2,493),
and length of stay was 77% longer (4.3 days to 2.4 days).0702

There is 1% of a scar dehiscence (the scar gives way) in a subsequent pregnancy
and a history of cesarean delivery increases the chance of cesarean section
being required next time.

The baby is more likely to have breathing difficulties if delivered by cesarean
section.

Informed Choice

It is essential that mothers should make an informed choice. In the UK, The
National Institute for Health and Clinical Excellence (NICE)
recommends that the benefits and risks of cesarean compared with vaginal birth
should be discussed. "Maternal request is not on its own an indication for CS
and specific reaons for the request should be explored, discussed and
recorded."

The Royal College of Midwives is campaigning for normal births as well, under
the banner: "Intervention and caesarean shouldn't be the first choice - they
should be the last."RCM

But choosing a Caesarean is not just a lifestyle issue, research
suggests. C- sections are the preferred way of giving birth for many
female doctors, possibly because they are aware of the risks of
childbirth.

Scottish female obstetricians, when asked for their personal choice
regarding delivery and showed that only 15.5% would choose elective
caesarean section compared with 31% and 21% in two surveys of London
female obstetricians.0201

One argument offered as a reason for elective cesarean section is the
protection of the pelvic floor. There is no doubt that vaginal delivery is a
major factor in the later development of urinary stress incontinence. While a
significant number of women's health care professionals are prepared to offer
cesarean delivery to nulliparous women, informed choice seems to motivate the
offer rather than a conviction that cesarean delivery will protect the pelvic
floor.0501

The caesarean section rate has been rising. Some private units
have 50% of their deliveries by caesarean. High rates of caesarean delivery do
not necessarily indicate better perinatal care and can be associated with harm.

So What is the answer to the rising cesarean section rate?

The decision on optimum mode of delivery is the most commonly
encountered question in clinical practice across all medical disciplines.

The number of factors to be taken into account is greater than
in any other clinical situation across all medical disciplines including:

Maternal age.

Obstetric history.

Maternal medical status.

Fertility problems.

Pregnancy complications.

Problems with the baby - eg small for dates -
placental insufficiency, large for dates/potential delivery
problems.

Patient choice.

There is undoubtedly a risk of litigation issue colouring
obstetric decision making. An obstetrician is more likely to be subjected to
litigation because a cesarean section was not performed or was perceived to have
been performed too late than for complications of surgery. In the current
climate, it is likely that cesarean sections are likely to continue rising.

This is the personal website of David A Viniker MD FRCOG, retired Consultant Obstetrician and Gynaecologist - Specialist Interests - Reproductive Medicine including Infertility, PCOS, PMS, Menopause and HRT.I do hope that you find the answers to your women's health questions in the patient information and medical advice provided.

I do hope that you find the answers to your women's health questions in the
patient information and medical advice provided.

The aim of this web site is to provide a general
guide and it is not intended as a substitute for a consultation
with an appropriate specialist in respect of individual care and
treatment.

David Viniker retired from active clinical practice in 2012. In 1999, he setup this website - www.2womenshealth.com - to provide detailed
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